Healthcare Provider Details

I. General information

NPI: 1407832116
Provider Name (Legal Business Name): LEANNE IRENE BUCK PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W NORTH ST
CORTEZ CO
81321-3117
US

IV. Provider business mailing address

20 W NORTH ST
CORTEZ CO
81321-3117
US

V. Phone/Fax

Practice location:
  • Phone: 970-565-7011
  • Fax: 970-565-3277
Mailing address:
  • Phone: 970-565-7011
  • Fax: 970-565-3277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAK605
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0004538
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: